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Patient Safety Primers

Greater availability of advanced diagnostic imaging techniques has resulted in tremendous benefits to patients. However, the increased use of diagnostic imaging poses significant harm to patients through excessive exposure to ionizing radiation.

Book/Report

Overuse of diagnostic imaging poses patient safety hazards, particularly for children. This report reviews techniques clinicians can use to discuss risks associated with using radiologic procedures with parents of pediatric patients. The publication includes answers to common questions about various types of tests and tips for enhancing conversations with parents.

Journal Article > Study

This analysis of incident reports related to magnetic resonance imaging found that, similar to other settings, incident reports are infrequent, and most do not result in patient harm. Common reasons for reports were associated with test orders, adverse drug reactions, and safety of intravenous medication administration. Given known under-reporting in voluntary reporting systems, future work should incorporate other safety hazard detection methods.

Test result notification is a longstanding patient safety problem. This time series analysis examined changes in documented communication between the interpreting radiologist and the treating physician for abnormal test results following implementation of an electronic alert notification system. The system allows radiologists to send alerts within their workflow for synchronous communication via pager for critical results and asynchronous communication via email for abnormal but noncritical results with alerts persisting until acknowledged by treating physicians. The authors used an automated text searching algorithm to identify radiology reports with and without documented communication and employed manual record review and adjudication to detect abnormal findings. They found that the electronic alert system led to higher levels of documented communication for abnormal findings without increasing documented communication of normal reports, allaying concerns about alert fatigue. This work demonstrates how systems thinking about provider workflow can result in technology approaches to enhance safety.

Collective intelligence encompasses several methods for summarizing input from multiple individuals, which can often be more accurate than any one expert. In this study, investigators applied several collective intelligence algorithms to mammography interpretation. They found that aggregating the interpretations of multiple radiologists resulted in higher accuracy—fewer false positive results and more true positive results—than even the most accurate single radiologist. This work builds on earlier studies of diagnostic accuracy in imaging studies. This study has profound implications for improving diagnosis through collaboration between clinicians in real time, perhaps facilitated through technology, as a complement to the long-standing diagnostic safety strategy of morbidity and mortality conferences, which provide group feedback once a case has concluded.

This innovative pilot study found significant improvement in radiologists' ability to detect wrong-patient errors when patient photographs were provided with radiographs. The authors advocate for including photographs with portable radiographs to prevent patient mislabeling errors and augment safety.

Journal Article > Review

Increased radiation exposure has emerged as a patient safety problem, with the potential to result in harm for providers and patients. This review explores how risk management tactics can be applied to radiology work and suggests development of quality systems, enhanced competency, transparency, and evidence-based protocols as ways to augment radiation safety.

Journal Article > Commentary

Radiation therapy has been described as an emerging patient safety issue due to harm associated with its use. This commentary describes a comprehensive analysis that identified risks related to ionizing radiation delivery and recommends solutions to enhance its safety.

Journal Article > Commentary

Although rare, adverse events still occur during magnetic resonance imaging (MRI). These incidents can be prevented through increased attention to the design of the environment in which scanners are used. This commentary describes the benefits to engaging frontline personnel in site planning to enhance MRI safety.

Journal Article > Study

Interruptions are inevitable for busy clinicians, and recently studies have shown that interruptions can increase workload for physicians and raise the risk of medication administration errors by nurses. However, these safety risks must be balanced against the fact that interruptions are often necessary for patient care. This study analyzed data from telephone logs and a formal quality assurance program to examine the effect of telephone interruptions on accuracy of on-call radiology residents' study interpretations. The authors found that a higher frequency of interruptions was associated with more diagnostic errors. This study is one of the first to document clinical consequences of physician interruptions and adds to our understanding of systems contributors to diagnostic errors. An incident involving an incorrect overnight radiology interpretation is discussed in a past AHRQ WebM&M commentary.

Lean, a work system improvement method drawn from engineering, is being increasingly used in health systems, but there is little evidence about how it affects patient safety. This study found that health care staff reported more positive safety culture after undertaking lean activities compared to their reported safety culture before participating, suggesting that efforts to improve health system efficiency may foster patient safety culture.

Similar to a prior smaller study, this study found the inclusion of point-of-care facial photographs obtained with portable chest radiographs increased the identification of wrong-patient errors among a group of 90 academic radiologists.

Recognizing and weighing harms associated with treatment is a core aspect of patient safety. Recently, low-dose computed tomography (LDCT) screening for lung cancer has been promoted by the 20% relative reduction in lung cancer-specific mortality found in a large clinical trial. This study evaluated National Lung Cancer Screening Trial data to determine an estimate of LDCT-detected lung cancer that would not otherwise become clinically apparent—or cancer overdiagnosis. Using these calculations, approximately 20% of cancers detected by LDCT screening represented overdiagnosis. From a research perspective, this study advances our understanding of the measurement of overdiagnosis, and this approach may also be useful for evaluating overdiagnosis of other conditions. A recent AHRQ WebM&M interview with Dr. Rebecca Smith-Bindman discussed radiation safety and the implications of increasing use of CT scans.

Cases & Commentaries

Admitted to the hospital after hours, a patient with a history of type A aortic dissection had his CT scan read as "no acute changes." However, the CT scan had been compared to a text report of a previous scan, rather than the images. The patient died several hours later, and autopsy revealed the dissection had progressed and ruptured.